Integrated Care Plans: Theory & Practice
Jessie M. Gaeta, MD
Boston Health Care for the Homeless Program
May 2015
Theory & Practice Theory
Concise snapshot of current priorities of team, across disciplines
Intent is to better coordinate care among ALL providers
Dynamic document – while overarching goals may persist, specific plans may change frequently
Practice
Culture shift, takes time
Emphasize empowerment of all team members to change plans
Case conferencing is the best mechanism for generating a plan
Make it front and center – don’t bury it in the note
The SPARK Center at
Boston Medical Center
Therapeutic childcare in a multidisciplinary team environment working in conjunction with primary and specialty care providers.
Making community connections.
Referral to feedback
Provider
Multi-disciplinary intake
Admission/
Transition
process
Testing
Observation
Assessment
Case review
Family meetings
Provider meetings
Parent conferences
SPARK children
• Medical issues such as VLBW infants, hypoxic brain injury, seizure disorders, respiratory problems, FTT, CP, ASD, cardiac defects, HIV, sickle cell, TBI
• Emotional/behavioral challenges: Impaired self regulation, neglect, physical and/or sexual abuse, parental loss, DV, trauma
• Have complex, overlapping challenges
• Have needs that can’t be met in other settings
• Are at highest risk for abuse/neglect
• Live in poverty
SPARK Team
• Educators - provide therapeutic, developmentally appropriate classrooms for content and social skills.
• EI Coordinator - provides assessment, referrals, transitions to public school
• Psychology clinicians -provide individual, family and group therapy, educational testing, home visits, development of care plans
• Nurses - provide assessment, health education, direct care, care coordination, adherence support, emergency triage
Care Plans
Community and home
• Respect for family values,
priorities and cultures.
• Value each discipline’s
contribution.
• Create communication
plan for follow up.
Moving on to school
• Parental letter to request evaluation.
• Testing happens at SPARK with appropriate input.
• SPARK staff attends IEP meeting.
• Contact with school staff as needed.
Protecting Privacy
• Privacy policies consistent with BMC.
• HIPAA and permission forms signed on
admission and updated each September.
• All staff adhere to yearly employee training
updates related to confidentiality.
Nursing
Nutrition
Gather medical data
Classroom assistance
Education
Small therapeutic classroom
1:1 ratio
Assessment (education and social)
DCF/Foster parent
Team meetings
Buy-in on “the plan”
Communication
Behavioral Health
Assessment
Behavioral intervention plan
Classroom assistance
Case Study
The SPARK Center 255 River St. Mattapan, MA 02126 Phone: 617-414-2050 Fax : 617-534-2057 www.bmc.org/SPARK
Patient Progress Report Case Review Date :___________________ Child:_______________________________ Current Age: ________________________ DOB:_______________________________ Date of Enrollment:___________________
Nursing and Early Intervention: ___Provider Initials
Developmental/Classroom: ___Provider Initials
Behavioral Health: ___Provider Initials
Family/Other: ___Provider Initials
------------------------------------------------------------------------------------------------------------------------------------
Assessment:
Plan:
Contacts: Karen Rogers Lynch, RN, Nursing Coordinator, 617-414-0505; [email protected] Catherine McCray-Manigault, Education Coordinator, 617-414-0509; [email protected] Martha Vibbert, PhD, Mental Health Coordinator, 617-414-0501; [email protected] Leah Koretz, ________________, 617-414-0517; [email protected]
Supporting Parents And Resilient Kids
1
Behavioral Health Care ManagementFamily Medicine Center at Boston Medical Center
Alysa N. Veidis RN, MSN, FNP-BC
May 12, 2015
2
Patient Centered Care
Patient
PCP
Pharm D
Patient
Navigator
Team Nursing
PsychiatristBH NP
LICSW
Team NP
MA
3
Care that is Coordinated
3
High
risk:
NP
managed
Hospital d/c
Uncontrolled disease
Moderate risk:
RN managed
1-3 chronic diseases
Low risk:
Medical Assistant/LPN managed
Preventative care outreach
4
Integrated Behavioral Health Model
Behavioral Health Team
PatientNavigator
LICSW NP Psychiatrist
• Resource expert
• Crisis intervention• Short course
psychotherapy for moderate complexity patients
• Substance use counseling• Group visits• Fam Med Rounds
• Psychopharmacology visits
• Depression Care Management
• Group Visits• Ongoing therapy• Fam Med Rounds
• Direct patient care (high risk)
• Consult Liaison
• PCP education
• BH oversight
Increasing complexity of behavioral health need
PCP/NP Teams
Care Management
Team
Co-management
5
Care Note
6
EMR Communication between LICSW and PCP
7
Communication- multi-pronged approach
Mode of Communication Detail
Warm Hand -Offs Daily and unscheduled
Curbsides/ Pages Ad- hoc and daily
EMR Progress Notes, and messaging in Centricity with security lock
All staff meeting Weekly Brief Updates and periodic agenda focus
Monthly Team Rounds Monthly Flash Rounds
Huddle Daily update on BH team schedule and availability
8
Concrete How To’s
Worth It:
1. Lay the Groundwork (“measure twice and cut once”)
2. Don’t underestimate the power of cross-departmental collaboration
3. Understand Behavioral Health Provider skill sets
4. Strategically place BH providers in the clinic (between exam rooms)
5. Understand billing and volume implications
6. Train , train and train some more
7. Communication and organization is KEY – you cannot over communicate!
8. Involve all levels of staff
9. Start small and spread
10. Decide on measures of success early